1
ASSESSEMENT OF DIARRHOEAL DISEASE
ATTRIBUTABLE TO WATER, SANITATION AND HYGIENE
AMONG UNDER FIVE IN KASARANI, NAIROBI COUNTY
HUMPHREY MBUTI KIMANI
P57/PT/10518/2008
A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE AWARD OF THE DEGREE OF MASTER
OF PUBLIC HEALTH (MPH) IN THE DEPARTMENT OF COMMUNITY
HEALTH, SCHOOL OF PUBLIC HEALTH, KENYATTA UNIVERSITY
July, 2013
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DECLARATION
This thesis is my original work and has not been presented for a degree in any
other university.
Sign:…………………………… Date ……………………………………………
Humphrey Mbuti Kimani
Department of Community Health
We confirm that the candidate, under our supervision, carried out the work
reported in this thesis.
SUPERVISORS
Sign:……………………………………….. Date:……………………………
Dr. Daniel Akunga (Ph.D)
Department of Environmental Health
Sign:…………………………………….. Date:…………………………………
Dr. Anyango S.O (Ph.D)
CASELAP
i3ii
DEDICATION
To my three sons: Kelvin, Ian and George who are currently pursuing various
educational programmes at different institutions.
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ACKNOWLEDGEMENT
Glory be to God for getting me this far. I am deeply indebted to my employer the
City Council of Nairobi and particularly my former boss Eng. Njenga who
ensured that I was granted time off when I requested during my study. May my
supervisors Dr. Akunga and Dr. Anyango from the Department of Environmental
Health And Environmental Sciences respectively be abundantly blessed for their
guidance and constructive criticism which has brought me this far. My gratitude
goes to the chairman of the Department of Community Health, Dr. Mwanzo for
supporting me in the many requests I made to the department. A lot of
appreciation to the staff in my office particularly my secretary Joyce who was
instrumental in producing this thesis. Mr. A. D. Bojana deserves gratitude for
editing the final work. Lastly, I wish to thank my research assistants, who
assisted me in the field. Further, I appreciate all research participants without
whose consent and cooperation the study could not have been a success.
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TABLE OF CONTENTS
Declaration ...............................................................................................................1
Dedication .............................................................................................................. 3
Acknowledgement ................................................................................................. 4
Table of Contents…………………………………………………………………v
List of Tables ......................................................................................................viii
List of Figures ......................................................................................................ix
List of Acronyms ................................................................................................... x
Abstract ...............................................................................................................11i
CHAPTER ONE: INTRODUCTION......................................................................1
1.1 Background to the Study....................................................................................1
1.2 Statement of the Problem ……………………………………………………. 5
1.3 Research Questions............................................................................................6
1.4 Study Objectives ................................................................................................7
1.5 Research Hypothesis..........................................................................................7
1.6 Justification and Significance of the Study........................................................7
1.7 Study Assumptions and Limitations ..................................................................9
1.8 Conceptual Framework for Diarrhoeal Diseases .............................................10
CHAPTER TWO: LITERATURE REVIEW ........................................................12
2.1 Introduction......................................................................................................12
2.2 Epidemiological Study of Diarrhoea ...............................................................14
2.3 Morbidity and mortality in relation to diarrhoea …………………………....18
2.4 Water, Sanitation and hygiene in relation to Diarrhoea...................................19
vi 6
2.4.1 Water quality and diarrhoea ……………………………………………19
2.4.2Sanitationanddiarrhoe …………………… 19
2.4.3 Hygine and diarrhoea disease .......................................................................23
2.5 Management, Control and Prevention of Diarrheoal Diseases .......................25
CHAPTER THREE: MATERIALS AND METHODS ........................................28
3.1 Location of the study………………………………………………………...28
3.2 Study Design...................................................................................................28
3.3 Target and Study Population............................................................................31
3.4 Inclusion and Exclusion Criteria.....................................................................31
3.5 Sample Size Determination.............................................................................32
3.6 Sampling Procedures ......................................................................................32
3.7 Data Collection instruments, Methods and Techniques .................................35
3.7.1 Household Data Collection Methods………………………………………35
3.7.2 Hospital Data Collection Methods................................................................36
3.8 Water Collection Methods ...............................................................................37
3.8.1 Water Sampling at Tap Level .......................................................................37
3.8.2 Water Sampling at Container level ...............................................................38
3.8.3 Laboratory Test.............................................................................................38
3.8.4 Test for Total Coliform Count ......................................................................39
3.8.5 Test for E.Coli...............................................................................................39
3.9 Data Management and Analysis……………………………………………..40
CHAPTER FOUR: RESULTS.……………………….. 41
4.1 Social Demographic Characteristic of Study Population…………………….41
v7ii
4.2 Childhood Diarrhoea Incidences and prevalence in the Study Area Between
2008 and2010…………………………………………………………………….43
4.3 Diarrheal Risk Factors Associated with WASH Conditions in the
Study Environs.......................................................................................................47
4.3.1 Water supply quality and quantity…………………………………………47
4.3.2.Diarrhoea Occurrences in the Study Area by Residential Environs .............48
4.3.3 Household Sanitation Coverage....................................................................49
4.3.4 Household and Personal Hygiene Practices……………………………… 50
4.3.5 Drinking Water and Household Water Storage Container Sanitary
Inspections…….…………………………………………………………...…….51
4.4 Household Water Contamination Level..........................................................52
4.4.1 Quality of Water consumed by the under five in kasarani……………… 52
4.4.2 Factors Associated with Social demographic and Household
Childhood Diarrhea................................................................................................54
4.5 Childhood Diarrhoea Risk Factors Associated with WASH Conditions........55
4.6 Discussion of the findings...............................................................................57
4.7 Diarrhoea cases in the study environs.............................................................57
4.7.1 Trends of childhood diarrhoea incidence and prevalence in kasarani…… 57
4.8 WASH risk factors related to childhood Diarrhoea in the study area.............58
4.8.1 Relationship between WASH and childhood diarrhoea in kasarani……… 58
4.9 Household water contamination level in the study environs ...........................61
CHAPTER FIVE: CONCLUSION AND RECOMMENDATIONS ....................62
5.1 Conclusions...................................................................... …………………..61
5.2. Recommendations...........................................................................................63
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5.3. Recommendation for Further Research ........................................................... 64
References ……………………………………………….…………………..…..65
Appendix I. Questionnaire for Household .............................................................71
Appendix II Consent form ……………………………………..……….……….79
Appendix iii/iv Patient Data Capture form…………………………….…… 80-81
Appendic v Laboratory Methods………………………………………………...82
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LIST OF TABLES
3.1 Estate Cluster for Kasarani study environs…………………………………..34
3.2 Health Facilities surveyed in the study area for pediatric records …..……...37
4.1 Socio-Demographic characteristics of the study pop…………………….......41
4.2 Mean Diarrhoea prevalence in the different residential 2008/ 2010………..44
4.3 Post anova analysis for the mean Diarrhoea prevalence in different residential
environs of Kasarani ……………………………………………………….……45
4.4 Water Supply and Quality…………………………………….……………...47
4.5 Diarrhoea occurrence of the under five disaggregated by study area. ……....48
4.6 Household sanitation coverage in the study area environs ………………….49
4.7 Household and personal hygiene behaviour in the study area……………….50
4.8 Household water storage container in the study area by residential environ...51
4.9 Level of Bacterial Contamination in Water Samples for Kasarani…..,,,,,,,,, ..52
4.10 The relationship between several social economic factors and childhood
Diarrhoea……………………………………………………………………...….54
4.11 Relationship between diarrhea and WASH ………………………………..55
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LIST OF FIGURES
1.1 Conceptual Models for Diarhoeal Diseases……………….……...................11
3.1 Maps of Kenya, Nairobi and Kasarani Division…………………....….…. ..30
4.1 Trends of Childhood Diarrhoeal Incidence in the Study Area 2008/3010 ....43
4.2 Association between Childhood Diarrhoeal Prevalence And Residential
Environs ….……………………………………………………………………...46
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LIST OF ACRONYMS
BDL BELOW DETECTABLE LEVEL
DHS DEMOGRAPHICS HEALTH SURVEY
EDC EPIDEMIOLOGICAL DISEASES CONTROL
EMCA ENVIRONMENTAL MANAGEMENT AND CORDINATION
ACT
E.COLI ESCHERICHIA COLI
GWAKO GROUND WATER ABSTRACTION IN KENYA UTREACH
HMIS HEALTH MANAGEMENT INFORMATION SYSTEMS
HHWC HOUSEHOLD WATER CONTAINER
HHT HOUSEHOLD WATER TAP
MDGs MILLENIUM DEVELOPMENT GOALS
LDHI LOW DENSITY HIGH INCOME
MDMI MEDIUM DENSITY MEDIUM INCOME
MOH MINISTRY OF HEALTH
HDLI HIGH DENSITY LOW INCOME
ISLI INFORMAL SETTLEMENTS LOW INCOME
NDDIS NATIONAL DIGESTIVE DISEASES INFORMATION
CLEARING HOUSE
NWSCO NAIROBI WATER AND SEWERAGE COMPANY
ORT ORAL REHYDRATION THERAPY
T.COLI TOTAL COLIFORM BACTERIA
UNICEF UNITED NATIONS CHILDREN’S FUND
UNDP UNITED NATIONS DEVELOPMENT PROGRAMME
WASH WATER SANITATION AND HYGIENE
WHO WORLD HEALTH ORGANISATION
xii 12
ABSTRACT
Cause of diarrhea is known to have many risk factors. They include unsafe water,
lack of water leading to low personal and domestic hygiene, poor water
infrastructural and management systems. Contamination of drinking water is
known to be a problem in many developing countries. This is even of more
concern in high residential low income areas. Nairobi City is not an exception
hence this study was conducted in Kasarani to assess diarrhea disease attributed to
water, sanitation and hygiene (WASH) among under-fives. The study aimed at
determining the quality of water the households were consuming. The main
objective of this study was to establish the association between diarrhea among
the under-five and water, sanitation and hygiene. To achieve this goal, the study
area was categorized in four study environs namely low density high income
(LDHI), medium density middle income (MDMI), high density low income
(HDLI and informal settlement low income (ISLI). The study adopted a cross-
sectional study design. The study used both structured questionnaire and hygiene
observational checklist as data collection instruments. To ascertain disease trends
among the under fives, the study reviewed disease records from licensed health
facilities. Derived values of tables, percentages, graphs and ratios were adopted
for data presentation. To determine association and significant differences
between variables, data were subjected to inferential statistics and Chi-square
tests respectively. For comparisons of quantitative variables, ANOVA test was
used. The findings of this study indicated that Nairobi water and sewerage
company ( NWSCO) was the main source of water supply in the study environs
(100%). Under five children from household consuming less than 60.75litres a
day and who were predominantly from (ISLI) were at a higher risk of diarrhoea
compared to those who consumed more than 60.75 litres a day (p<0.001).
Households experiencing water shortages in frequencies of less than three days
were found to carry a higher risk for childhood diarrhoea (p< 0.001). This study
determined that water consumed in Kasarani was a risk for childhood diarrhoea
(p=0.019) with tap water showing a significantly higher contamination 13.7%
than household water container 7.2% for T. Coli bacteria. The microbial results
observed attributed contamination to the distribution network or household and
personal hygiene among the MDMI, HDLI and ISLI residential environs. Overall,
the results indicated that the amount of water a household consumed per day was
an important risk factor for childhood diarrhea in the study environs (p= 0.001).
The study observed that Age of a child (p=0.046), Water treatment method
(p=0.002), method of storage of solid waste p<0.001, quantities and frequencies
of water supply (p<0.001) were found to be the most important risk factors for
childhood Diarrhoea. The study determined that there was a significant difference
in the mean Diarrhea incidences and prevalence across the residential environs
(F= 422.995, df=3, p<0.001, F=96.691, df=3, p<0.001. There was a strong linear
association between ddiarrhea prevalence and the different residential environs.
R2 = 0.88, 0.899 and 0.886 in the year 2008, 2009 and 2010 respectivey. The
findings established that children in ISLI were the most affected by ddiarrhea.
The study concluded that there was a relationship between childhood diarrhoea,
water, sanitation and hygiene in Kasarani Division. These study recommended
that NWSCO institute programmes that will facilitate adequate and wholesome
water supply and distribution to HDLI and ISLI residential environs respectively.
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CHAPTER ONE
INTRODUCTION
1.1 Background to the Study
Diarrhoeal disease kills an estimated 2.2 million people each year (WHO, 2009).
Among infectious diseases, Diarrhoea is ranked as the third leading cause of both
mortality and morbidity (UNICEF, 2008). Young children are especially
vulnerable bearing 68% of the total burden of diarrhoea disease (WHO/UNICEF,
2005). Among children less than five years, diarrhoea accounts for 17% of all
deaths (WHO/ UNICEF, 2009).
The infectious agents associated with diarrhoea disease are transmitted chiefly
through the faecal oral route (WHO, 2008). The wide variety of bacteria, viral and
protozoa pathogens excreted in the faeces of humans and animal are known to
cause diarrhoea. Among the most important of these are Escherichia coli (E. coli),
Salmonella sp; Shigella sp; Campylobacter jejuni, Vibrio cholera, Rotavirus,
Norovirus, Giandia lamblia, Cryptosporidium sp; and Entamoeba Histolytica
(WHO/UNICEF, 2009).
Bacteria agents as a group are believed to cause a majority of diarrhoeal diseases
in developing countries, while viral and protozoa agents tend to cause more cases
in developed countries (Hunter, 1997).
2
Many of the diarrhoeal agents are potentially waterborne transmitted through
ingestion of contaminated water (Hunter, 1997). Intervention for the prevention
and control of diarrheal diseases not only include enhanced water quality but also
steps to improve sanitation, increase the quality and improve access to water
supply, and promote hand washing and other hygiene practices within domestic
and community settings (WB, 1992). Health authorities generally accept that
microbiologically safe water plays an important role in preventing outbreaks of
waterborne diseases (Hunter, 1997).
Accordingly, the most widely accepted guidelines for water quality allow no
detectable level of harmful pathogens at the point of distribution (WHO/UNICEF,
2005). However, an estimated 1.1 billion people lack access to improved water
supplies (WHO/UNICEF, 2000). In settings that are not served by reliable water
treatment and distribution systems, diarrhoeal disease is often endemic
WHO/UNICEF, (2000).
With improvement in the quality of drinking water, there is evidence of increased
health benefits (Esrey 1996). According to global water, ,sanitation and hygiene (
WASH, 2008) fast facts, water, sanitation and hygiene have the potential to
prevent at least 9.1% of the global disease burden and 6.3% of all deaths.
Further, (WHO/UNICEF, 2006) observes that improved sanitation could save the
lives of 1.5 million children per year who would otherwise succumb to diarrhoeal
diseases. Unsafe drinking water, inadequate availability of water for hygiene and
3
lack of access to sanitation together contribute to about 88 % of the deaths from
diarrhoeal diseases or more than 1.5 million of the 1.9 million on children
younger than 5 years of age who perish from diarrhoea each year mostly in
developing countries. This amounts to 18% of all the deaths of children under the
age of five leading to more than 5,000 children dying every day as a result of
diarrhoeal diseases (WHO/UNICEF 2006).
In Africa and especially Sub-Saharan Africa, diarrhoeal diseases account for over
90% of deaths in children below five years old (WHO, 2007). This has been
attributed to lack of safe drinking water, sanitation and hygiene as well as poor
nutrition (Water Aid, 2001). Accordingly, improved water sources reduce
diarrhoea morbidity by 21%, improved sanitation by 37.5% and hand washing by
as much as 35% (WHO, 2005).
WHO/UNICEF, 2006 further observes that the regions with the lowest coverage
of improved sanitation in 2006 were Sub-Saharan Africa (31%), Southern Asia
(33%) and Eastern Asia (65%). In Kenya, diarrhoeal disease is the major cause of
childhood morbidity and mortality (IDRC, 2006). According to the 2010 National
Policy Guidelines to redouble diarrhoea disease management and control efforts
by the Ministry of Public Health and Sanitation, untreated diarrhoea kills and is
the third leading cause of death in children under five years in Kenya.
The policy also observes that, while many Kenyans have gained access to safe
drinking water, the majority still lack access to proper sanitation. Globally, Oral
4
rehydration therapy has however dramatically decreased the mortality associated
with diarrhoea but has had little effect on morbidity estimated to be approximately
4 billion cases per year (Kosek, 2003).
With continued high attack rates, diarrhoeal disease is also an enormous economic
burden resulting in significant direct costs to the health sector and patients for
treatment as well as in cost time at school, work and productive activities
(Mulligan, 2005). An estimated 94% of the diarrhoea burden of disease is
attributable to the environment and associated with risk factor such as unsafe
drinking water, lack of sanitation and poor hygiene (Pruss- Ustun & Corvalan,
2006).
Traditionally, economic evaluation of water and sanitation has focused on
infrastructural improvements- mainly construction of facilities to improve water
supplies and excrete disposal. According to the data available at the City Council
of Nairobi, Epidemiology and Disease control section for 2010, diarrhoeal
diseases remain the second cause of morbidity in the children under 5 years in
Nairobi with Kasarani District reporting an average of 1000 cases of diarrhoea per
month (HMIS, 2010).
Arising from the observed serious public health problem, this research intended
to study the association between water, sanitation, hygiene and diarrhoeal diseases
among the under five years of age in Kasarani Division.
5
1.2. Statement of the Problem
Childhood diarrhea is a leading cause of morbidity and mortality in Nairobi City.
Inspite of the ministry of public health and sanitation together with the other
stakeholders in the public health sector developing health education and
awareness and other environmental health programs to avert the situation, the
disease continues to ravage many children below the age of five.
In deed many childhood illnesses in Kenya are water related. Diarrhea remains
one of the most important childhood environmental health problems. However
research has indicated that diarrhoea is a function of water, sanitation and
hygiene. According to a report from Waterwiki, 2010 transmission of diarrhoea
and water-related diseases are directly linked to inadequate access to water and
hygiene practices.
In Nairobi City, only one third of the population is served with the conventional
water and sewerage systems (NWSCO, 2008). In Kasarani study area,
developments of structures and infrastructures are not fully controlled. The
household income levels range from higher to lower income earners respectively.
It is a mixed development with both residential and commercial activities taking
place. Kasarani division has a population of approximately 525,000 people (Pop
census, 2009). In most of the areas, there is no conventional drainage system.
The systems to improve sanitation are pit latrines, septic tanks and soakpits.
Further, there is no conventional solid waste management system. Water supply
6
source is from Nairobi Water and Sewerage Company. Distribution of the water
to the plots is mostly facilitated by the plot owners. The type of the water
distribution pipes are not well-fitted hence constant breakages from the pressure
of the many activities associated with housing and infrastructural developments
and therefore resulting to probable contamination of water and limited access to
household water supply.
According to the health records obtained from the City Council of Nairobi (EDC,
2011), diarrhoea-related morbidity among children under five were the most
commonly reported in the 2008/2011 period in Nairobi city with Kasarani having
the highest cases of diarrhoea. However, whether this risk factor has contributed
to the diarrhoea situation in the study area is not documented. This research
therefore, intended to establish the association between the observed diarrhoeal
incidences among children under five in Kasarani Division and water, sanitation
and hygiene,
1.3 Research Questions
i. What is the incidence and prevalence of diarrhoea among children under
five in the study area?
ii. Is there a diarrhea risk associated with water. Sanitation and hygiene
(WASH) conditions among children under five in Kasarani, Nairobi?
iii. What is the microbial quality of water used by the residents?
7
1.4 Study Objectives
The main objective of the study was to determine the relationship between WASH
conditions and occurrence of diarrhoea episodes among the under five years of
age in Kasarani, Nairobi City.
The specific objectives included:
i. To establish diarrhea incidences and prevalence of the under five years of
age in the study area.
ii. To determine diarrhea risk factors associated with water, sanitation and
hygiene (WASH) conditions among the under five years of age in the
study area.
iii. To determine the level of bacterial contamination in the water consumed
by under five in the study area.
1.5 Research Hypothesis
i. The occurrence of diarrhoeal disease among under five in Kasarani is not
attributable to water, sanitation and hygiene.
1.6 Justification and Significance of the Study
Mortality and morbidity data for diarrhea incidences can be used to assess the
level of health of a population in a region. The same information can be used to
assess and compare the economic status of a region as demonstrated by UN
MDG’s in WHO regions. According to UN MGOs 2000 and Kenya Vision 2030
8
on health, Kenya has committed itself to reducing child mortality rate by two
thirds among children under five years.
Byers (2001) observes that unsafe water, sanitation and hygiene (WASH) risk
factor plays a predominant role in the outbreak of Diarrhoea disease whose
transmission pathways are influenced by such factors as infrastructure, water
availability, inappropriate disposal of faecal wastes and behavioural aspects. A
study by Esrey et al (1996) suggests an important role for each intervention in the
reduction of diarrhoea disease and also notes the health benefits resulting from the
reduction in diarrhoea illnesses that relate to improvements in water, sanitation
and hygiene.
The same interventions have been observed to have positive effects on the
illnesses such as Schistosomiasis, Ascariasis and respiratory outcome which are
also related to poor methods of excreta disposal. Conducting surveillance in order
to establish diarrhea disease trend for different social economic and geographical
environments can be made possible from diarrhoea incidences information.
The same information can be used to provide the basis for future projections and
evaluations of different control strategies. Diarrhoea incidence data are also
important indicator of the level of hygiene of individuals’ sanitation and
availability of improved water sources (UN, 2000). Further this information is
also a tool to identify overall health inequalities in the population besides forming
9
the basis for identifying control priorities, effectiveness of interventions, costs and
actions.
1.7 Study Assumptions and Limitations
Nairobi City has a well-established health management information system. This
has been enhanced through the current decentralized Health Service delivery. This
study therefore assumes that the diarrhoea incidences occurring in Kasarani have
been registered through an established Health Information Systems in the
surrounding health clinics. It also assumes that those health clinics are registered
by the relevant Health Registration Boards.
Further, it assumes that the health records identify each of the diarrhoea
incidences with age, sex, and residence. However, this study acknowledges that
there are other factors that may also influence the health outcome of a population
and include state of health of the population, nutritional status, water management
and distribution systems especially water distribution, storage, hygiene practices,
social/cultural factors, environmental and type and use of sanitary facilities. The
complexity of the relationship therefore qualifies infections and transmission of
diarrhoea as illustrated in the conceptual framework.
10
1.8 Conceptual Framework for Diarrhea Diseases
Diarrhea prevalence is influenced by the interplay of many risk factors. Among
them are:
a) Social economic status: These include the mother’s education levels,
marital status and the household’s income levels.
b) Infrastructural factors: These factors include sanitation and living
conditions for example sewerage systems, source of water supply, nature
and type of toilets.
c) Hygiene factors: These factors include both household and personal
hygiene behavior
d) Demographic factors: These factor include age and gender of the child’s
care giver respectively.
11
Social economic status
Household specific indicators Mother’s or child’s
-water supply care takers indicators:
-Number of people per room -Occupational status
(crowding), frequency of -education level
garbage collection - Marital status
Neighbourhood infrastructure, sanitation &
living conditions
Infrastructure & Household living
sanitation
condition
-Sewerage systems
-Type of habitation
coverage
-Source of water supply -Quality of ground
-Waste disposal methods -Nature & type of toilets
Hygiene practices
Age Diarrhoea prevalence
Gender
er
Figure 1.1: Conceptual framework visualizing the inter-relationships between
potential risk factors and Diarrhea prevalence
Source: Genser B et al., Int. J. Epidemiol. 2008; 37: 831-840
12
CHAPTER TWO
LITERATURE REVIEW
2.1 Introduction
Globally, diarrhoea is the second highest cause of mortality in children under five
years of age (WHO/UNICEF, 2010). According to WHO Global Burden of
disease 2004 estimates, Diarrhoea accounts for nearly 1.8 million deaths or 17%
of under five mortality each year in developing countries. WHO estimates that
85% to 90% of diarrhoea illnesses in developing countries can be attributed to
unsafe water, inadequate sanitation and hygiene practices (Pruess et al. 2004).
Diarrhoea is defined as having three or more loose or liquid stools per day or
having more stools than is normal (WHO, 2009).
It is a common cause of death in developing countries and the second most
common cause of infants’ deaths worldwide (Hogue, 1996). The loss of fluids
through diarrhoea can cause dehydration and electrolyte imbalances. In 2009,
diarrhoea was estimated to have caused 1.1 million deaths in children over five
years and 1.5 million deaths in children under the age of five. Oral rehydration
salts and zinc tablets are the treatment of choice and have been estimated to have
saved 50 million children in the past 25 years (WHO/UNICEF, 2000).
There are many causes of infectious diarrhoea, which include viruses, bacteria
and parasites. Norovirus is the most common cause of viral diarrhoea in adults but
Rotavirus is the most common cause of death in children under five years old.
13
Adenovirus types 40 and 41 and Astroviruses cause a significant number of
infections (WB, 1992). The bacterium Campylobacter is a common cause of
bacterial diarrhea but infections by Salmonella, Shigellae and some strains of
Escherichia Coli (E.Coli) are frequent. The organisms in the total coliform groups
are called indicator organisms.
Its presence in water requires an analysis of all water systems facilities and their
operations to determine how these organisms entered the water system (NPHLS,
2008). E Coli is a specific species within the Coliform bacteria. Its presence
indicates a strong likelihood that human or animal wastes are entering the water
system (NPHLS, 2008. Amoeba usually lives in the large intestines sometimes
invading walls of the intestines forming a cyst. This causes ulcerations and
bleeding with bouts of dysentery occurring. In 20% of the infected cases, no
symptoms show.
It is fecal oral and spread through a cyst (WHO, 2010). Crypto infection is spread
through fecal oral route and often through contaminated water. It affects the
intestines and is usually acute. It is the organism most commonly isolated in HIV
positive patients presenting with diarrhea (WHO, 2010). In the elderly,
particularly those who have been treated with antibiotics for unrelated infections,
a toxin produced by Clostridium Difficile often causes severe diarrhoea (NDDIC,
2007).
14
In sanitary living conditions where there’s ample food and a supply of clean
water, an otherwise healthy person usually recovers from viral infections in a few
days (Kosek, 2003). However, for ill or malnourished individuals, diarrhoea can
lead to severe dehydration and can become life threatening. According to Moses
et al 2010, most of the pathogenic organisms that cause diarrhoea and all the
pathogens that are known to be major causes of diarrhoea are transmitted
primarily or exclusively by the faecal-oral route.
Faeco-oral transmission may be waterborne, food borne or direct transmission
which implies an array of other faeco- oral routes such as via fingers or formites
or dirt which may be digested by young children. According to a survey by Nisha
and Nicholas (2010), despite the severe impact of diarrhoea on children’s health
and mortality in India, only half of all children suffering from diarrhoea receive
treatment or medical advice. An understanding of the socio-demographic
determinants for appropriate treatment of the disease is critical.
2.2 Epidemiological Study of Diarrhoea
Diarrhoeal diseases are one of the leading causes of childhood morbidity and
mortality in developing countries. An estimated 1000 million episodes occur each
year in children under the age of five. Diarrhoea causes an estimated 5 million
deaths in children under five years of age per year. About 80% of these deaths
occur in children in the first two years of life. Approximately, 1/3 of deaths
among children under five are caused by diarrhoea (WHO, 1990). In Philippines,
15
diarrhoeal disease is the second leading cause of morbidity and mortality for all
ages it is the next leading cause of infant deaths. The most important bacterial
infections gain entry through the gastro- intestinal tract They include the bacillary
dysenteries, cholera and enteric fevers.
This is one of the most commonest causes of childhood diarrhea. Contamination
of water remains the cause of major outbreaks. It can occur through cross
connection of a main with a polluted water supply, fecal contamination of wells or
faulty purification. Similarly, amoebiasis and giardiasis which live in the large
intestines cause ulcerations of the mucosa with consequent diarrhea. It is known
to occur most in tropics and subtropical countries. Infected water has occasionally
been held responsible for the transmission of large outbreaks of the disease.
Surveys done in La Union, Bohol and Bukidnonin 1985 showed that every
Filipino child suffered an average of 2.8 episodes annually. Most diarrhoeal
illnesses are acute, usually lasting no more than 3-5 days and are secondary to
infectious causes. Infectious agents that cause diarrhoeal disease are usually
spread by the faecal-oral route, specifically by ingestion of contaminated food or
water and contact with contaminated hands.
The usual pathogenic mechanisms for infectious diarrhoea include toxin
production, tissue invasion, or invasion of intestinal cells with consequent
acceleration of their function and reproduction. The most common organisms
16
responsible for most cases of diarrhoea include Rotavirus, ETEC Shigella,
Campylobacter, Vibrio Cholera and non-typhoidal Salmonella.
A serologic survey conducted in metro Manila In 1990 showed early acquisition
of antibodies for Rotavirus. 7% of Sporadic diarrhoea was caused by Rotavirus in
the community while 35% was detected in the hospital cases. Infection due to
Norwalk virus was however not uncommon. More studies on the prevalence of
antibodies to Norwalk virus in Manila showed that 43% of individuals would
have detectable levels by age 12 years. Isolation rates for Salmonella, Shigella,
EPEC, V. Cholera 01 and other Vibrios, campylobacter Jejuni and Aeromoeas SP.
differed from study to study. Contrary to popular belief, Entamoeba Histolytica
was detected in less than 5% of cases.
The prevalence survey done in the Philippines showed that only 5% of 14,205
stool specimens were positive for the parasite and 6% 19,771 sera had antibody
titers-1,128 by indirect hemagglutination. The percentage isolation of Giardia
Intestinalis was likewise low. Besides, the etiologic agents mentioned above,
other conditions causing or are associated with diarrhoea include drugs, surgical
conditions, other diseases e.g. (malaria, Schistomiasis, Measles), systematic
infections and food intolerance. A number of pathogens have, also been
associated with persistent diarrhoea and dysentery.
These types of diarrhoea are important in that they are more likely to have severe
consequences. Studies have shown that one third to one half of all diarrhoea-
17
associated deaths among children occurred following episodes of persistent
diarrhoea where dysentery accounts for 10% to 15% of diarrhoea episodes in
children under the age of 5, but up to 25% of diarrhoea deaths.
Dysentery is caused primarily by bacteria which invade the epithelial cells of the
small intestine and colon, produce a variety of toxins, disrupt the cell and cause an
inflammatory response. A number of organisms have been found in dysentery
cases and more than one pathogenic organism is found in many cases. However,
Shigella is the most common (from 33% to 62% of cases in 3 studies). The second
most common cause of dysentery is Campylobacter. Others include invasive
E.Coli, P. Shigelloides, Salmonella and Aeromonas SP. An estimated 1.1 billion
people lack access to an improved water source.
Hundreds of millions more drink contaminated water from improved sources
because of unsafe water treatment and distribution systems and unsafe storage and
handling practices. (UNICEF, 2006).
The health consequences of inadequate water and sanitation services include an
estimated 4 billion cases of diarrhoea and 2.2 million deaths each year, mostly
among young children in developing countries (WHO, 2008). In Kenya, diarrhoea
ranks as the third leading cause of both mortality and morbidity among infectious
diseases (Care/Kenya, 2005). According to a report by Gwako (2010), 23.3
million Kenyans do not have access to safe drinking water resulting to several
deaths (mostly children).
18
A pilot project with the Care/Kenya in 2005 on preventing diarrhoea disease in
Nyanza Province showed that water quality intervention reduced diarrhoea
disease incidence in users by 22 - 84% through the Safe Water System. This
included water treatment with chlorine solution at the point of use, storage of
water in a safe container and behaviour change communication. Results from the
project showed a 56% reduction of diarrhoea disease risk with improved hygiene
level.
2.3 Morbidity and Mortality in relation to Diarrhoea Disease
Diarrhoeal diseases have long been recognized as a leading cause of morbidity
and mortality, especially in developing countries (WHO, 2008). International
efforts to combat this worldwide problem include the recent initiation by the
World Health Organization of a diarrhoeal diseases control programme whose
objective is to reduce diarrhoeal morbidity and mortality.
A study by WHO to quantify the magnitude of the global problem of acute
diarrhoeal disease established that morbidity rates were highest in the 6-11 month
age group while the mortality rates were greatest in infants under 1 year of age.
For children under 5 years old, the media incidence of diarrhoea was 2.2 episodes
per child per year for all studies and 3.0 episodes per year for the studies that had
the smallest populations and most frequent surveillance.
The studies also estimated that the total yearly morbidity and mortality from
diarrhoeal diseases for children under 5 years of age in Africa, Asia, were 744
+000 million episodes and 4.6 million deaths (WHO, 2008). Snyder and others
19
acknowledge the obvious limitations inherent in estimating the global incidence
of diarrhoeal illnesses and death on the basis of data obtained in studies conducted
by different researches using different methods of study discrete populations. A
different study by Bern et al., (2007) observed that the median number of 2.6
episodes of diarrhoea per child per year is little different from the estimated 2.2
episodes reported by Snydes and others and is equivalent globally to an estimated
1 billion episodes each year.
The medians and ranges for mortality, among children aged less than 5 years with
past population estimates yield an estimated 3.3 million deaths per year from
diarrhoea, lower than 4.6 million deaths previously reported. However, the range
is wide. Although there are inherent limitations in this study, it has been possible
to estimate the magnitude of the problem of acute diarrhoeal diseases in the
developing world.
2.4 Water, Sanitation and hygiene in relation to Diarrhoea Disease
2.4.1 Water quality and diarrhoea
The prevalence of contamination from man-made pollution and waste to naturally
occurring toxins and the wide range of ways contaminated water can enter the
human body are staggering. Everyday people are put at risk through drinking
contaminated water, eating food prepared in bowls or with utensils washed with
contaminated water, through poor personal hygiene, bathing and washing in
unhygienic water.
20
Over 3 million people die each year nearly all from developing countries with
80% of the total disease burden coming from the poor countries (WHO, 2007). It
is estimated that up to half of all hospital beds in the world are occupied by
victims of water contamination.
The biggest killer is diarrhea contracted from micro-organisms in water
contamination by sewage resulting in 1.8million child deaths per year. In places
like Sub-Saharan Africa and south Asia, up to half of all cases of malnutrition are
caused by diarrhoea. Various studies and outbreak incidences have found an
association between poor water quality and diarrhoea.
In Togo water that did not meet microbiological standards was associated with
increased gastroenteritis while in Philippines increased childhood diarrhea was
observed following consumption of water with high levels of Escherichia Coli
(Moe et al.1991). In developing countries, it is not only water contamination at
source or during distribution that is an issue but also water stored within the home
which may also become contaminated (WHO/UNICEF, 2007). In the United
States, 14 outbreaks of infectious etiology associated with drinking water were
reported for the two year period 1997-1998 (Barwick et al. 2006).
21
2.4.2 Sanitation and diarrhoea diseases
The health consequences of inadequate water and sanitation services include an
estimated 4 billion cases of diarrhoea and 1.9 million deaths each year, mostly
among young children in developing countries (Waterwiki, 2010). Diarrhoea
diseases lead to decreased food intake and nutrient absorption, malnutrition,
reduced resistance to infection and impaired physical growth and cognitive
development. Water and sanitation interventions to reduce diarrhoea disease
incidence in developing countries fall into four general categories: Water
provision, household water treatment, hand washing promotion and sanitation.
Each of these interventions is proven to reduce diarrhoeal disease incidence.
Survey by the Department of Physical and Health Knowledge and Practice among
secondary school children in Zaria & Nigeria and diarrhoea observed that poor
knowledge and practice of personal health and environmental health increased
prevalence of diarrhoea among children of school age (Ingrid, 2008).
Organizations are often faced with the difficult decision of where to focus limited
resources in order to improve water and sanitation conditions.
Selecting the most appropriate interventions for a specific location depends on
existing water and sanitation conditions, cultural acceptability, hydrology and
water quality, implementation, feasibility and local conditions (Waterwiki, 2010).
According to WHO Health related MDG’s 4 and 7, countries were to reduce child
mortality rate and also ensure environmental sustainability by the year 2015.
22
Currently, 1.1 billion people worldwide lack access to safe water supplies which
include household connections, public standpipes, boreholes and protected dug
wells, protected springs and rainwater collection (UNICEF, 2006).
According to a report by WHO/UNICEF, (2008) on global statistics on children,
water and hygiene, water supply, sanitation and diarrhoea are closely related. Poor
hygiene, inadequate quantities and quality of drinking water and lack of sanitation
facilities cause millions of the world’s poorest people to die from preventable
diseases each year. Women and children are the main victims. The link between
water, sanitation and diarrhoea include:-Contaminated water that is consumed and
may result in waterborne diseases including viral hepatitis, typhoid, cholera,
dysentery and other diseases that cause diarrhoea. Without adequate quantities of
water for proper hygiene, skin and eye infections for example trachoma spread
easily (WB, 2003). In some areas like Turkana, the prevalence rate is 42%
(AMREF, 2011).
Inadequate water, sanitation and hygiene account for a large part of the burden of
illness and health in developing countries. Approximately 4 billion cases of
diarrhoea per year cause 2.2 million deaths, most of them children under the age
of five with about 15% of deaths in developing countries. Diarrhoeal diseases
account for 4.3% of the total global burden (62.5 million DALYS). An estimated
88% of this burden is attributable to unsafe drinking water supply, inadequate
23
sanitation and poor hygiene. These risk factors are second after malnutrition, in
contributing to the burden of the disease.
Improving global access to clean water and sanitation is one of the least expensive
and most effective means to improve public health and save lives. The concept of
clean water and sanitation as essential to health is not a novel idea. Hippocrates in
350 B.C is quoted to have recommended boiling of water to inactivate impurities.
A proceeding from the royal society of London on appropriate technologies for
environmental health on water, sanitation and diarrhoea observes that in the
developed countries where water and sanitation services are nearly universal,
hygiene-related diseases have been significantly reduced.
This has been through the protection of water sources and installing sewerage
systems. This however, is not the case in developing countries and as a result,
millions suffer and die from preventable illnesses including diarrhoea every year.
The solution lies on integrating public health into engineering problem solving.
The paper recommends partnerships with local communities to implement water
and sanitation solutions that consider environmental, cultural and economic
conditions.
2.4.3 Hygiene and Diarrhoeal Diseases
Research by (Curtis et. al., 2003) on Myanmar experiences in sanitation and
hygiene promotion observed that washing hands after defecating was protective
while providing safe drinking water and more latrines and promoting hand
24
washing could reduce the burden of illness from bloody diarrhoea while limiting
injudicious antimicrobial use. It was also observed that hand washing could
reduce diarrhoea risk by 47% while hand washing with soap reduced diarrhoea
risk from 42-44%.
The current evidence however indicates that hand washing with soap can reduce
the risk of diarrhoeal diseases by 42-47% and interventions to promote hand
washing might save a million lives. According to a study by (Hoque, 2003) in
Bangladesh and elsewhere, hand washing is universally promoted in health
interventions. The study has shown a 14-40% reduction of diarrhoeal diseases
with hand washing. The study observes that perceptions and methods related to
washing of hands vary widely. Socio-economic factors are also associated with
methods practiced.
The prevalence of contamination from man-made pollution and waste to naturally
occurring toxins and the wide range of ways contaminated water can enter the
human body are staggering. Everyday people are put at risk through drinking
contaminated water, eating food prepared in bowls or with utensils washed with
contaminated water, through poor personal hygiene, bathing and washing in
unhygienic water.
Over 3 million people die each year nearly all from developing countries with
80% of the total disease burden coming from the poor countries (WHO, 2007). It
25
is estimated that up to half of all hospital beds in the world are occupied by
victims of water contamination.
The biggest killer is diarrhea contracted from micro-organisms in water
contamination by sewage resulting in 1.8million child deaths per year. In places
like Sub-Saharan Africa and south Asia, up to half of all cases of malnutrition are
caused by diarrhoea. Various studies and outbreak incidences have found an
association between poor water quality and diarrhoea.
In Togo water that did not meet microbiological standards was associated with
increased gastroenteritis while in Philippines increased childhood diarrhea was
observed following consumption of water with high levels of Escherichia Coli
(Moe et al.1991). In developing countries, it is not only water contamination at
source or during distribution that is an issue but also water stored within the home
which may also become contaminated (WHO/UNICEF, 2007). In the United
States, 14 outbreaks of infectious etiology associated with drinking water were
reported for the two year period 1997-1998 (Barwick et al. 2006).
2.5 Management, Control and Prevention of Diarrhea diseases
A number of measures can prevent diarrhoea diseases from manifesting. They
include breast feeding, which provides infants the antibodies to protect against
infections. Improved weaning practices, proper use of improved weaning
practices, proper use of water for hygiene and drinking, hand washing, disposal of
feaces properly, vaccinations and proper nutrition. (Jailson et al., 2010). To
26
implement these strategies, the people must be educated about proper practices
and utilize the community health workers and village health workers.
For case management, oral rehydration therapy (ORT) is the oral administration
of water and electrolytes to replace existing losses, primarily accomplished by
giving oral rehydration salt (ORS solutions. According to WHO/UNICEF, 1999,
there is evidence that ORT was an ancient traditional practice. Research in 1990s
demonstrated that the addition of glucose to salt solution resulted in absorption of
salt and water across the intestines (WHO, 2005). In the absence of glucose no
absorption of salt or water was observed. The same research observed a dramatic
decrease in mortality rates from diarrhoea (30% to less that 3%) with the
administration of ORT in refugee camps in Bangladeshi war for independence. In
addition to ORT, appropriate feeding during episodes of diarrhoea is
recommended.
Clinical and laboratory studies show that continued feeding during episodes of
diarrhoea leads to improved outcomes in diarrhoeal diseases. They include
decrease in stool output, shortened duration of illness, significant weight gain and
improved nutritional status ((WHO, UNICEF, 1999). Nutritional therapy depends
on the age and diet of the child. (Bell et al., 2010). For infants, the importance of
breastfeeding is stressed. WHO recommends exclusive breast feeding for the first
few months.
27
Research has shown that where mothers have to breastfeed, exclusively; there is a
dramatic decrease in episodes of diarrhea (UNICEF, 2005). Breast feeding
should be supplemented with ORT. Scientific research has suggested a
relationship between diarrhoea and specific micronutrients deficiencies. Zinc
deficiency may cause diarrhoea. Vitamin A deficiency is associated with risk of
diarrhoea while folic acid may be associated with improved recovery time for
acute cases of diarrhea (UNICEF, 2005).
According to WHO, 2008 drug therapy of diarrhoea should be avoided. This is
because some drugs may be potentially toxic to some patients leading to adverse
reactions. Non-compliance with therapy may also lead to antibiotic resistance.
The WHO therefore recommends that anti-diarrhoea drugs be strictly avoided as
they may prolong infection and mask signs of dehydration. Although the standard
WHO/UNICEF ORS solution is effective in achieving and maintaining
rehydration, it does not reduce stool volume or duration of diarrhoea illness.
Super ORS have recently been developed which reduce stool and increase water
absorption in the gut. A vaccine for diarrhoea caused by Rota virus has also been
developed.
28
CHAPTER THREE
MATERIALS AND METHODS
3.1 Location of the Study
The study was carried out at Kasarani Division Nairobi County. Kasarani
Division is a residential area and in the eastern part of Nairobi. The Division has
seven locations. They are; Githurai, Kahawa, Kariobangi, Kasarani, Korogocho,
Roysambu and Ruaraka. . Kasarani residential estates ranges from the low density
high income to informal settlement low income. The infrastractural development
in terms of water distribution, sewerage systems and waste disposal is either low
or lacking particularly in the informal settlement unlike in the high income areas.
It’s about 10 km from the city centre along thika road and in Nairobi North
District.
Kasarani Division has a population of approximately 525,000 people and covers
an area of 86km2 (KNBS, 2009). The housing development comprises different
designs and structures. It is a mixed development for both rental and individual
residence purposes.
Most of the housing developments have not been approved by the relevant
institutions and enforcement of city by-laws is not adequate (NEMA, 2009). This
has led to mushrooming of poorly built structures that are both permanent and
semi-permanent and which poses serious public health concerns. The water
supply source is Nairobi Water and Sewerage Company (NWSCO). However,
29
water distribution in the area is mostly through plastic pipes, each plot having a
supply tap water. With the various developments taking place, breakages of pipes
are common risking water contamination. This is made even more grave because
in most areas, there is no convectional drainage system and the existing system is
through the septic tanks, soaked pits and pit latrines. There is equally no
established method of solid waste management and most residents practice
indiscriminate solid waste dumping (JICA, 2010).
3.2 Study Design
This study was a cross-sectional design. The design was chosen since it was
meant to determine prevalence of risk factors of diarrhoea incidences among the
under five in Kasarani and examine the association with water, sanitation and
hygiene. Hence a reconnaissance survey was conducted to identify the households
and Health Facilities to be sampled.
To establish Diarrhea incidence and prevalence, a retrogressive purposeful study
covering three years was used to evaluate data on Morbidity and mortality from
the neighboring licensed health clinics. The simple random sampling method was
employed to collect the water samples from the eligible Households.
30
Map of Kenya
Map of Kasarani
Figure 3.1 Map of Study Area in relation to its position in Kenya
Source: Google Maps
31
3.3Target and Study Population
The study targeted all the children below the age of five residing in Kasarani
Division of Nairobi County. Kasarani Division covers an area of approximately
86km2 with a resident population of 525,000 people (KNBS, 2009). Further, it has
approximately 10500 households (CBS, 2002). Since the study targeted child
caregivers as respondents the target population was 10500 households in the area.
The child caregiver was however anyone who was responsible for the child at the
time of the study in that household and could have been the mother, father, house
help or any other person.
3.4 Inclusion and Exclusion Criteria
Households included in the study had to have members who had lived there for at
least one year. The household had to be serviced with a source of water supply
whether from tap or communal tap. Further the household had to have a child
below the age of five years and the respondent had to be willing to participate.
32
3.5 Sample Size Determination
Sampling in research is the process of obtaining information about an entire
population by examining only a part of it (Kothari, 2003). It serves the purpose of
saving time and other resources and yet produces the required results. This
happens by the researcher drawing inferences based on samples about the
parameters of population from which the samples are taken. In this research, the
sample size was determined using the formula by Fisher et al., (1998).
n=Z2pq
d2
Where n=desired sample size.
Z=standard normal deviate at 95% confidence level (1.96)
P= proportion of the households target population with children under five
years 15% (UNEP, 2009).
q=1-P
d=degree of accuracy desired (0.05)
n=1.962(0.15)(0.85/0.052
n=196
3.6 Sampling Procedure
Kasarani division was conveniently selected. The residential estates of Kasarani
were then clustered into four study environs based on characteristics presented in
table 3.1. This followed the 2009 Kenya National Bureau of Statistics household
cluster sampling methodology. Following this clustering, simple random sampling
33
technique was used to select participating estates according to probability
proportionate to sample size.
However, before selecting sample environs, implicit stratification was achieved
through first stage sampling by sorting estates using a socio-economic status
(SES) indicator. To be able to select participating households in each of the
selected estate, simple random sampling technique was again employed according
to probability proportionate to sample size (KDHS, 2009). To determine the
probability proportionate for the sample size for each cluster, the formula by
Kothari, 2003 was adopted where the cluster household population was divided
by the total household population and then multiplied by the total sample size.
Overall, a total of 199 eligible households representing 31, 53, 56 and 59
households in LDHI, MDMI, HDLI and ISLI respectively were sampled.
34
Table 3.1 Estate Cluster for Kasarani study environs and corresponding
households
No Cluster Estates Households Environmental Sanitation Characteristics
LOW Kasarani 550 Low population
DENSITY Sports View Drainage system not connected to main sewer
1. HIGH
INCOME Thome 450 (NWSCO)
Developments & Structures are controlled
Mirema Drive
500 Solid waste management is well organized
Water supply distribution pipes well maintained
Waste water effluents well managed
Majority of the houses are owner occupiers
Water supply source (NWSCO)
Sanitation methods are septic tanks and soak pits
which are well maintained
Ngumba 850 High population
Occupants both owner occupiers and tenants
2. MEDIUM Zimmerman 1000 Source of Water (NWSCO)
DENSITY Waste water discharging to the surrounding
MIDDLE environment
INCOME Water supply distribution pipes poorly
maintained
Roysambu 1000 Sanitation method is septic tanks
Solid waste generation high but fairly well
managed
Developments& structures not fully controlled
HIGH Mathare North 1100 High population
DENSITY Has poor drainage system
LOW Manguu Solid waste poorly managed
3. INCOME Developments& structures not fully controlled
925 Household are generally rental dwellings
Water supply source(NWSCO)
Githurai 44 Water supply and distribution pipes poorly
maintained
1000
INFORMAL Jathaini 1025 Communal toilets are the most in use.
SETTLEME /Ngomongo 1000 Poorly managed solid wastes
4. NT LOW 1100 Informal settlements
INCOME Soweto Fairly high population and overcrowding
Kahawa Houses are generally for rental dwellings
Water supply distribution pipes poorly managed
Kamae Waste water overflowing to the surrounding
Kahawa West environment
Water supply source is NWSCO but generally
inadequate and therefore supplemented from
water vendors.
Ref- (KNBS, 2009)
35
3.7 Data Collection Instruments, Methods and Techniques
3.7.1 Household Data Collection Methods
Households were visited to list and identify eligibility. After initial listing, two
trained research assistants then visited each household for data collection and
sanitation inspections using the structured household questionnaire. However,
before commencement of the data collection, respondents’ consent to participate
was sought. The respondents were asked to identify the source, frequency and
quantity of water used in the household as well as type and form of sanitary
facilities available for their use.
Sanitary inspections were conducted through visual assessment of the
infrastructures and the sanitary state surrounding the household water supply,
water holding containers; among other household sanitary conditions taking into
account the sanitary aspects and practices in water handling that posed an actual
or potential risk to water quality, health and wellbeing of the child.
Further, the respondents were asked whether any of the children in the
household had experienced diarrhoea in the last one month prior to the visit. If
the answer was yes, the respondent was asked the age of the child at the time of
infection, whether treatment was sought and from where and the symptoms and
signs of the episode (Ingrid, 2008).
36
3.7.2 Hospital Data Collection Methods
Health facilities operating within the selected estates were visited to review
childhood diarrhea-related morbidity and mortality records. The selected health
facilities were purposively and conveniently selected and matched with the
particular selected estate as identified in the initial survey. Thereafter a structured
data capture form was developed to collect the data (Appendix v/vi).
The key parameters for this review included the residence of the visiting child,
diarrhea had been clinically diagnosed, age in months of the child suffering from
diarrhea episode and the duration of diarrhea episode. This information was then
used to match the hospital case with the selected estate (Table 3.2). All cases that
had no information on residence were dropped from this study (Madise et al.,
2003).
Further, each case was reviewed to identity the sex of the child, age in months,
date of the onset, location and residence of family, duration of the episode and
treatment outcome. The data were then cleaned and the information entered on to
the research database (Madise et al., 2003).
37
Table 3.2: Health facilities surveyed in the study area for review of the
paediatric records
Study environs Visited health facility Matched field study.
LDHI St. Francis Hospital Kasarani
Neema Hospital Thome
MDMI Glovanna Sylvia Hospital. Mirema
Baba Ndogo Health Centre Ngumba
HDMI Frema Hospital Zimmerman
Marurui Health Centre Roysambu
ISLI Mathare North H. Centre Mathare North
Kasarani Health Centre Manguu
St. John’s Hospital Githurai 44
Kiambu District Hospital Ngomongo/Njathaini
Kahawa West Health Centre Soweto/Njuakali
Kamiti G.K Prison H. Centre. Kamae
3.8 Water Collection Methods
3.8.1 Water Sampling at Tap Level
A water sample was collected from each household visited. For the collection of
water samples, a 250ml glass stopper bottles were used. The bottles were cleaned
and carefully rinsed using standard procedure (EMCA, 2007). The bottles were
then wrapped in aluminum foils and sterilized in an oven overnight at 170°c. On
the day of sampling, the sterilized bottles were packed in a sterilized ice cooler
38
box and transported to the site of the sampling. At the time of sampling, the bottle
caps were carefully removed by hands covered by sterilized gloves.
The tap was turned full and the water allowed to run to waste for two or three
minutes. The tap was then turned off. The outside of the bottle was cleaned using
dry cloth; the tap was framed with a blow lamp for two minutes. The bottle was
filled with the water running gently to avoid splashing (NPHLS, 2008). The
stopper and paper cap and label were replaced and dispatched to the laboratory
packed ice in an insulated box.
3.8.2 Water Sampling at Container Level
Water samples were collected from the household water container level. In
collecting the sample, a sterilized rope was tied around the neck of the sterilized
sampling bottle to avoid water contamination. The water sampling bottle was then
dropped into the water container. Once the water sampling bottle was full with the
water, it was capped with a sterilized cap and then the water sample was clearly
labelled (NPHLS, 2008) and transported to the laboratory for analysis.
3.8.3 Laboratory Test
270 water samples were processed at the food and water sampling laboratory of
the Nairobi city county. After the samples were received in the laboratory for
bacteriological examination of water, they were cultured immediately or stored in
a refrigerator to control deterioration. The laboratory preparation procedure
involved making dilutions of the sample (1:10, 1:00, 1:000 etc) in sterile water